21.1 Introduction and Overview
695
Amnestic Disorder
Amnestic disorders
are classified inDSM-5 as
major neurocognitive
disorders caused by other medical conditions
. They are marked pri-
marily by memory impairment in addition to other cognitive symp-
toms. They may be caused by (1) medical conditions (hypoxia),
(2) toxins or medications (e.g., marijuana, diazepam), and (3)
unknown causes. These disorders are discussed in Section 21.4.
Clinical Evaluation
During the history taking, the clinician seeks to elicit the devel-
opment of the illness. Subtle cognitive disorders, fluctuating
symptoms, and progressing disease processes may be tracked
effectively. The clinician should obtain a detailed rendition of
changes in the patient’s daily routine involving such factors as
self-care, job responsibilities, and work habits; meal prepara-
tion; shopping and personal support; interactions with friends;
hobbies and sports; reading interests; religious, social, and rec-
reational activities; and ability to maintain personal finances.
Understanding the past life of each patient provides an invalu-
able source of baseline data regarding changes in function, such
as attention and concentration, intellectual abilities, personal-
ity, motor skills, and mood and perception. The examiner seeks
to find the particular pursuits that the patient considers most
important, or central, to his or her lifestyle and attempts to dis-
cern how those pursuits have been affected by the emerging
clinical condition. Such a method provides the opportunity to
appraise both the impact of the illness and the patient-specific
baseline for monitoring the effects of future therapies.
Mental Status Examination
After taking a thorough history, the clinician’s primary tool is
the assessment of the patient’s mental status. As with the physi-
cal examination, the mental status examination is a means of
surveying functions and abilities to allow a definition of per-
sonal strengths and weakness. It is a repeatable, structured
assessment of symptoms and signs that promotes effective com-
munication among clinicians. It also establishes the basis for
future comparison, essential for documenting therapeutic effec-
tiveness, and it allows comparisons between different patients,
with a generalization of findings from one patient to another.
Table 21.1-1 lists the components of a comprehensive neuropsy-
chiatric mental status examination.
Cognition
When testing cognitive functions, the clinician should evaluate
memory; visuospatial and constructional abilities; and reading,
writing, and mathematical abilities. Assessment of abstraction abil-
ity is also valuable, although a patient’s performance on tasks such
as proverb interpretation may be a useful bedside projective test in
some patients, the specific interpretation may result from a variety
of factors, such as poor education, low intelligence, and failure to
understand the concept of proverbs, as well as from a broad array of
primary and secondary psychopathological disturbances.
Table 21.1-1
Neuropsychiatric Mental Status Examination
A. General Description
1. General appearance, dress, sensory aids (glasses,
hearing aid)
2. Level of consciousness and arousal
3. Attention to environment
4. Posture (standing and seated)
5. Gait
6. Movements of limbs, trunk, and face (spontaneous, resting,
and after instruction)
7. General demeanor (including evidence of responses to
internal stimuli)
8. Response to examiner (eye contact, cooperation, ability to
focus on interview process)
9. Native or primary language
B. Language and Speech
1. Comprehension (words, sentences, simple and complex
commands, and concepts)
2. Output (spontaneity, rate, fluency, melody or prosody,
volume, coherence, vocabulary, paraphasic errors,
complexity of usage)
3. Repetition
4. Other aspects
a. Object naming
b. Color naming
c. Body part identification
d. Ideomotor praxis to command
C. Thought
1. Form (coherence and connectedness)
2. Content
a. Ideational (preoccupations, overvalued ideas, delusions)
b. Perceptual (hallucinations)
D. Mood and Affect
1. Internal mood state (spontaneous and elicited; sense of
humor)
2. Future outlook
3. Suicidal ideas and plans
4. Demonstrated emotional status (congruence with mood)
E. Insight and Judgment
1. Insight
a. Self-appraisal and self-esteem
b. Understanding of current circumstances
c. Ability to describe personal psychological and physical
status
2. Judgment
a. Appraisal of major social relationships
b. Understanding of personal roles and responsibilities
F. Cognition
1. Memory
a. Spontaneous (as evidenced during interview)
b. Tested (incidental, immediate repetition, delayed recall,
cued recall, recognition; verbal, nonverbal; explicit,
implicit)
2. Visuospatial skills
3. Constructional ability
4. Mathematics
5. Reading
6. Writing
7. Fine sensory function (stereognosis, graphesthesia,
two-point discrimination)
8. Finger gnosis
9. Right-left orientation
10. “Executive functions”
11. Abstraction
(Courtesy of Eric D. Caine, M.D., and Jeffrey M. Lyness, M.D.)
